Nursing Elites

1. When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take?

• A. Deflate the cuff completely and immediately reattempt the reading.
• B. Re-inflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
• C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
• D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.

Correct answer: C

Rationale: When the nurse is unable to distinguish the point at which the first sound was heard while taking a client's blood pressure, the best action is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Deflating the cuff for this duration allows blood flow to return to the extremity, ensuring an accurate reading on that extremity a second time. Option A of deflating the cuff completely and immediately reattempting the reading could lead to a falsely high reading. Option B, re-inflating the cuff completely and leaving it inflated for 90 to 110 seconds, reduces circulation, causes pain, and may alter the reading. Option D, documenting the exact level visualized on the sphygmomanometer where the first fluctuation was seen, is not a reliable method for assessing blood pressure and does not address the issue of obtaining an accurate reading.

2. Which response would the nurse make to a client with schizophrenia who claims to be Joan of Arc about to be burned at the stake?

• A. ''Tell me more about being Joan of Arc.''
• B. 'We both know that you're not Joan of Arc.''
• C. ''It seems like the world is a pretty scary place for you.''
• D. 'You're safe here, because we won't let you be burned.''

Correct answer: C

Rationale: The nurse would say, ''It seems like the world is a pretty scary place for you.'' This response allows the nurse to understand the symbolism, reflect on and acknowledge the client's feelings, and help preserve the client's integrity. The statement, ''Tell me more about being Joan of Arc,'' validates the client's delusion and does not test reality. The statement, ''We both know that you're not Joan of Arc,'' rejects the client's feelings and does not address the client's fears of being harmed; clients cannot be argued out of delusions. The statement, ''You're safe here, because we won't let you be burned,'' is false reassurance; the nurse is agreeing with the client's false perceptions of reality, which is nontherapeutic.

3. Which instruction should the nurse provide to a preschool-age client to prevent altered growth and development?

• A. Trust
• B. Empathy
• C. Impulse control
• D. Problem-solving

Correct answer: C

Rationale: Teaching a preschool-age child and their parents about the importance of impulse control is essential to prevent the risk of altered growth and development. Preschool-age children are at a stage where they are developing self-regulation skills, so teaching them to manage their impulses can help in their overall growth and development. Trust is a critical concept taught during infancy to foster secure attachments. Empathy is crucial for parents of toddlers to understand their child's emotions. Problem-solving skills are typically emphasized for school-age children to enhance cognitive development.

4. The family of a child with cerebral palsy (CP) is at risk for difficult parenting issues. Which basis would the nurse conclude as the probable cause for this difficulty?

• A. Lack of social support
• B. Unrealistic expectations
• C. Loss of the expected healthy child
• D. Having a child with cognitive impairment

Correct answer: C

Rationale: The correct answer is 'Loss of the expected healthy child.' Parents of a child with cerebral palsy often grieve the loss of the healthy child they expected, mourning what could have been and what may never be. While lack of social support can contribute to parenting difficulties, it is not the primary basis in this case. Unrealistic expectations may play a role for some parents, but not all. Additionally, it is important to note that not all children with cerebral palsy experience cognitive impairment; around 30% to 50% of children with cerebral palsy have cognitive challenges.

5. The client is still unable to sleep despite following the progressive muscle relaxation technique routine taught by the nurse. Which action should the nurse take first?

• A. Instruct the client to add regular exercise to their daily routine.
• B. Determine if the client has been keeping a sleep diary.
• C. Encourage the client to continue the routine until sleep is achieved.
• D. Ask the client to describe the routine they are currently following.

Correct answer: D

Rationale: The nurse's initial step should be to assess the client's adherence to the original instructions. By asking the client to describe the routine they are following, the nurse gains more specific information than relying solely on a sleep diary. This information will help the nurse identify any deviations or areas needing adjustment in the technique. Encouraging the client to persist with an unsuccessful routine without evaluation is not beneficial. Adding regular exercise, although important for overall sleep health, should come after ensuring the correct execution of the relaxation technique.

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